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File: 092496_aug96_decls4_0014.txt
Subject: PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91
Unit: ARCENT
Parent Organization: CENTCOM
Box ID: BX000460
Folder Title: MEDSTAT- SITREPS - JANUARY - 1
Document Number: 10
Folder SEQ #: 2
16:16:50 tm PATIENT FILE 01/04/91
PBMNL' DATA - PRIVAI.Y ACT CF 1974
5 U.S.C. 552 (b)(6)
13. MOBEE A
MK-.- is. AUNRITY #: OU&037 2. SBAN-@ 3. PRECEDENCE: R
4. STAT: All 3. GME: E03 6. AGE: 23Y 7. SEX: M B. WT. 160 9. READY DATE: 365
10. ISO- It. POR: 12. SPEC CAT:
14. REAS REG: DS 15. DATE LAST VISIT: 16. CLASS: 3A
17. ACCEPT PHYS: J?Rg 19. APPT/SLIRB DATE: NO
20. P.PPROV AJTH: 21. Ci%N:/INC: 22. VALID: S?IF Y2
23. KrF DRIG: A5150 LISA D19MA.RY DPAM 24. ICA3 CRIS- CEDR
2@@. MW DEST: A5040 2M GM HOSP LA,%M, 26. ICAD DEST: BAR
27. P.ED SPEC 1: MR 28. DIAS 1: 71650 @CIFIED POLYARTHRCPATHY, PCLYARTMITIS, SITE L;NSPECIFIED
29. rED SPEC 2: 30. DIAS 2:
31. MED SPEC 3: 32. DIAG 3-
32A. PROCEDUR---.
33. SOEC DIET: NI 34. IV:
M: N 36. SU6T: N 37. NS TUBE: N 38. RESP: ti 39. FCLEY: N 40. STRYKER: N
41. INAM. N 42. TRACT-.N 43. ItB: N 44. CAST/LC@'. N 45. TRACH: N 46. rn..I: N
7',. PT BAG TYPE: NB 72. PT BAG TAG 4: 73. PT BAG WT:
47. SLIPP IWO: C CO 299 ENG.R B.4 FT SILL DK ///FLEET 5 ////
49. MAX ENRTE STGPS: Y 9 49. VAX # RC%NS- Y / 9 50. ALT FEST/t'AX HT: N i
53. INPATIENT,. Y 54. SPEC PROS: VA DRLIS ALCOHOL WT NON--' X 55. VA CODE:
56. ADMIWMMEAS-
58. VITAL 916'iS(TE)tP/PULSE/RESP/BLOOD PRESS): 096.8 68 / 16 / 122 82
59. iB: 60. ICT: 61. ABS: DATE TAKEN:
62. WBC: 63. SI/VSI: 64. KOICATIO%'S: NONE
65. HISTGRY: 9 ?MM HISM OF RIGHT HIP PA14 - PATIENT UNABLE TO WORK-
t;--EDS Mm
66. ATT PHYS: WILKEFTS 67. PH#,. 438 943 8943 68. WILRD#/PH#: 894 / 389 438 9438
69. REPORTED BY- DREYER 70. PH#: 473 SM7
74. ATTEM4T NAME #1: 75. STATUS: 76. 6RADE:
77. AGE. 78. SEXT 78A. MT-. 79. RELATIONSHIP TO PATIENT:
63. BAS TYPE: St. BAG TAS 0: 82. BAB WT-
84. STATUS: 85. 6RADE:
86. AGE: 87. SEX: 87A. WT: 88. RELATIONSHIP TO PATIENT-
69. BAG TYPE: 90. BAB 7AS 91. BAG @IT:
92. TRA'IS CRIG PF.OQ EXT-
93. TRAIS DESR PFZ'E EXT:
94. ETA CRIS KrF(DATErfIKE): 000 95. ETA DEST tff (DATE/TIME): 000
97. OTHER Ss
5'.. MSN #: 0000/365 52. RON LOC:
57. VPLIDATB BY/REAS FOR H@.S PRECEDENCE:
96. AIRCRAFT ITIN-tRiLRY:
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Document 31 f:/Week-31/BX000460/MEDSTAT- SITREPS - JANUARY - 1/personal data privacy act of 1974 4 jan 91:09209615580712
Control Fields 17
File Room = aug96_declassified
File Cabinet = Week-31
Box ID = BX000460
Unit = ARCENT
Parent Organization = CENTCOM
Folder Title = MEDSTAT- SITREPS - JANUARY - 1
Folder Seq # = 2
Subject = PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91
Document Seq # = 12
Document Date =
Scan Date =
Queued for Declassification = 01-JAN-1980
Short Term Referral = 01-JAN-1980
Long Term Referral = 01-JAN-1980
Permanent Referral = 01-JAN-1980
Non-Health Related Document = 01-JAN-1980
Declassified = 20-SEP-1996